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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200512
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:33:56 AM

Document Has Been Signed on 09/08/2022 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSE'S GARDEN ADULT RESIDENTIAL #3FACILITY NUMBER:
079200512
ADMINISTRATOR:JOSE RODRIGUEZFACILITY TYPE:
735
ADDRESS:3106 TABORA DRIVETELEPHONE:
(925) 864-7564
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rosa Menjivar-Nunes. AdministratorTIME COMPLETED:
10:40 AM
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On 9/8/2022 at 9:35AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Rosa Menjivar-Nunes. Administrator, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 98.7 degrees Fahrenheit. Fire extinguisher last serviced on 6/24/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Infection Control Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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